COMPREHENSIVE BENEFITS AND CLAIMS ADMINISTRATION

August 8, 2005   HFCC-FT, AFT 1650 HEARING BENEFITS Hearing Aids  90% up to $600 per device (Limited to one device per year, per 24 month period) Exam 100% (Limited to one exam in a 24 month period) Covered Charges The Plan will pay as shown in the Schedule of Benefits, for the following services and supplies: (1) Examinations by a licensed hearing technician or Physician; (2) Medically Necessary prescription hearing aid devices. Exclusions No benefit will be paid for the following: (1) Excess. Cost of exams or devices which exceed the Plan allowance. (2) Exclusions. Charges listed under Plan Exclusions. (3) No prescription. Non-prescription hearing devices. (4) Medical. Medical and surgical treatment of the ear or ear canal. (5) Replacement. Replacement of lost or broken devices unless the Covered Person is eligible for benefits at that time. Third Party Administrator: CBCA, Inc. P.O. Box 902 Beattyville, KY 41311 Phone: (800) 832-3709 FAX: (952) 946-7547 EMPLOYEES CAN CALL CBCA AT 800-832-3709 To verify eligibility and benefits call: CBCA at 800-832-3709 BILLING INSTRUCTIONS
NO CLAIM FORMS ARE REQUIRED, however, in order for bills to be processed without delay, the following information must be provided on the statement.
1. Name of Employer -Henry Ford Community College	6. Provider's Name and Tax       I.D.
2. Group Number -100750	7. Date of Service
3. Name of Employee	8. Description and Diagnosis
4. Name of Patient	9. If accidental injury, describe       how, when and where the       accident happened.
5. Employee Number -Social Security Number	10. Other coverage information
SEND CLAIMS TO: CBCA Administrators PO Box 902 Beattyville, KY 41311 FAX Number: 952-946-7547 E-Mail: GR-customer service@cisgi.com Website: CBCA Quick Login